Call for Action to Improve Global Access to Insulin

Miriam E Tucker

February 08, 2016

More efforts need to be devoted to ensuring global access to insulin for people with diabetes, according to a new in-depth review by three public-health experts.

The document was published online February 5 in Lancet Diabetes & Endocrinology by David Beran, PhD, of the division of tropical and humanitarian medicine, Geneva University Hospitals and the University of Geneva, Switzerland, and colleagues.

"Substantial attention has been given to the issue of access to medicines for communicable diseases; however, access to essential medicines for diabetes, especially insulin, has had insufficient focus….Very little has been done globally to address the issue of access, despite the [United Nation's] political commitment to address noncommunicable diseases and ensure universal access to drugs for these disorders," the authors write.

Insulin is essential for the survival of people with type 1 diabetes and is needed for improved management of diabetes for some people with type 2 diabetes. But today, nearly a century after its discovery, poor access to insulin translates to a life expectancy as low as 1 year following onset of type 1 diabetes in a child in sub-Saharan Africa.

And the problem isn't limited to low- and middle-income countries: even in the United States, one study found that discontinuation of insulin use due to high cost was the leading cause of diabetic ketoacidosis in people in an inner-city setting (Diabetes Care. 2011;34:1891–1896).

The new paper outlines the complexity of the problem — including the economic, regulatory, and political aspects — and provides a call to action with potential remedies. The document is aimed at all stakeholders, including professionals who care for people with diabetes, Dr Beran told Medscape Medical News.

"Healthcare workers play an essential role in ensuring that their patients have access to insulin and the necessary education for its use. I also believe that in many settings they should also help advocate for people's access to insulin where this is problematic....The call to action applies for all those who are concerned about the well-being of people with diabetes," he stressed.

Affordability and Availability

The new review describes the first stage of a 3-year study entitled Addressing the Challenge and Constraints of Insulin Sources and Supply (ACCISS), a collaboration of Dr Beran's institution, Health Action International, and Boston University's School of Public Health.

The authors have combined medical literature from different settings and used specific country examples to highlight certain issues.

"This global study aims to provide a greater understanding of the complexity and causes of poor access to insulin and to develop interventions tailored to the different challenges countries might face," the authors state.

As background, they note that, in September 2011, the UN declaration on noncommunicable diseases and subsequent sustainable development goals reflects commitments by member states to address access to drugs, along with strengthening health systems and providing universal health coverage.

Yet, Dr Beran and colleagues say, despite this declaration, very little has been done globally to address the issue of insulin access, with several factors contributing to the problem.

There are issues of affordability of insulin to healthcare systems and to individuals.

In WHO and Health Action International surveys, there is a huge range in the price paid for insulin by governments — across 10 studies, for example, the cost of a range of insulin formulations varied from $2.55 to $48.25 per vial.

Dr Beran and colleagues also publish a bar chart showing the cost of insulin in different countries for the individual, in both the public and private sectors.

And they stress that insulin also needs to be available, both at a national level — something that can be assessed by the presence of insulin on national essential-medicine lists and guidance as to where insulin should be present, for example health centers vs hospitals — and at a global level.

Three Companies Dominate Global Insulin Market

The global control of the insulin market by three multinational companies means that countries have a small number of suppliers to choose from, and this has often resulted in people having to change the type of insulin they take as companies have withdrawn formulations from the market or hiked up the price of insulin analogues.

At the same time, regulatory aspects around biosimilars have limited the availability of cheaper alternatives. The shift from use of vials to the more expensive patented pen devices also plays a role, the authors note.

In linking both the availability and affordability elements, only six of the countries surveyed would meet the WHO's 80% availability target of affordable insulin in the public sector, the authors note.

They also point out that insulin alone "is not enough for proper diabetes management, which also requires syringes, blood glucose meters, education, information, and family support."

They issue a call to action, including the following:

  • Allocation of 5% of funds by diabetes funders for innovation in the delivery of care and insulin.

  • Inclusion of insulin in universal health coverage benefit packages.

  • World Health Organization investigation of prequalification of insulin, development of a regulatory framework for biosimilars and insulin, and promotion of existing guidelines and methods for effective purchasing of quality-ensured, safe, efficacious, and cost-effective insulin products.

  • Development of a global compact with the insulin industry to guarantee that human insulin and insulin in vial form will not be removed from the market.

  • Ensuring that organizations and academics speak with a unified voice when calling for better diabetes care.

Dr Beran said, "People in 2016 still face poor health and even death as they cannot access insulin, which was discovered in 1921….We hope that this paper raises the issue."

The work was supported by the Leona M and Harry B Helmsley Charitable Trust. The study authors have no further relevant financial relationships.

Lancet Diabetes Endocrinol. Published online February 5, 2016. Abstract

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